Professional Documents
Culture Documents
from the research literature as well as expert opin zation, 1999). The term velopharyngeal impair
ion. They address some of the major issues in the ment refers to any failure of the velopharyngeal
management of children and adults with dys mechanism to open or close in a normal fashion for
arthria. Practice guidelines are intended for use in speech (Tomes & Kuehn, 1996).
making clinical decisions about the management of
specific clinical problems. In this article, guidelines
for the management of velopharyngeal impairment PROCEDURES: REVIEWING
in dysarthria are reviewed. THE EVIDENCE
searched: PsychINFO covering 1,300 journals (1967 The rating scheme is described more fully else
to July 2000), MEDLINE covering 3,900 journals where (Yorkston et al., 2001). A table of evidence
(1966 to July 2000), and CINAHL covering 600 jour was then created that contained a summary of each
nals (1982 to July 2000). The initial searches were study and allowed comparisons among studies and
keywords paired with the term dysarthria, for ex over time.
ample, dysarthria and velopharyngeal, dysarthria
and hypernasality, dysarthria and resonance. Later
searches paired terms such as velopharyngeal, hy Expert Reviews
pernasality, and resonance with the terms speech The quality of evidence found in the intervention
and treatment. Because the intent was to carry out literature along with the expert opinion of the writ
the broadest possible search, other sources of evi ing committee was summarized in a technical re
dence were also sought. In addition to the electron port. A draft of this report was made available to a
ic searches, hand searches of relevant edited books larger panel of expert reviewers. In the case of
in the field of dysarthria and ancestral searches of these practice guidelines for management of
extant references (e.g., studies cited within an arti velopharyngeal impairment, the technical report
cle or chapter) were conducted. was reviewed by 28 experts in addition to the writ
ing committee. A majority of these individuals hold
Criteria for Inclusion of Studies doctoral degrees (6 1%). The average length of clini
cal practice was 19 years. Although most of the ex
The general search on the topic of dysarthria yield pert reviewers were members ofANCDS (68%), the
ed 1,042 references. From this large search, refer opinion of reviewers from outside of the organiza
ences related to velopharyngeal function were tion’s membership with known expertise on
identified, and those related to intervention were velopharyngeal function was also sought. The com
obtained and rated. Intervention studies were de ments of the expert reviewers were carefully con
fined as those focusing on treatment of the velopha sidered and used to modify the technical report. Fi
ryngeal system that was applied to at least one per nally, the guidelines were distributed in the form of
son with dysarthria. Thus, articles were excluded both a technical report, made available on the web-
that (a) described but did not treat velopharyngeal sites of ANCDS (http://www.duq.edulancds/) and
function in dysarthria, (b) applied treatment ap ASHA (http:llwww.asha.org[), and published in this
proaches to individuals without impairment, and clinically focused article.
(c) studied techniques for management of velopha
ryngeal impairment associated with disorders other
than dysarthria, (e.g. cleft palate). Review articles SUMMARY OF EVIDENCE FROM
and chapters that surveyed intervention served as INTERVENTION STUDIES
supportive documentation for a flowchart of man
agement decisions described later in this article. A total of 33 intervention studies were identified,
obtained, and rated by at least two members of the
Rating the Evidence writing committee. A sunirnary of the table of evi
dence in which the studies were rated can be found
Each intervention study was analyzed for method in the technical report. The following section pro
ological rigor. Strength of evidence was rated ac vides an overview of the evidence, including the
cording to principles outlined by the American Psy types of interventions and management of velopha
chological Association (Chambless & Hollon, 1998) ryngeal impairment in dysarthria.
and was determined by asking the following series
of questions:
What Interventions Are Reported
How well were the subjects described? in the Research Literature?
How well was the treatment described? The intervention studies were classified into three
categories: prosthetic, surgical and exercise. Pros
What measures of control were imposed in the thetic intervention included palatal lifts, nasal, or
study? nasopharyngeal obturators and palatal desensiti
Were the consequences of the intervention well zation associated with palatal lift fitting. Surgical
described? intervention included pharyngeal flap surgery,
EVIDENCE-BASED PRACTICE GUIDELfl’ES FOR DYSARTHRIA 261
pharyngeal implants, and teflon injections. Exer type speech in the absence of cleft palate” (Randall,
cise included palatal training devices and resis Bakes, & Kennedy, 1960). Other studies published
tance exercises with continuous positive airway prior to 1970 are called “preliminary” reports
pressure (CPAP). Table 2 contains a summary of (Hardy, Rembolt, Spriestersbach, & Jaypathy, 1961)
the types of interventions for velopharyngeal im and lack both the detailed case descriptions and
pairment reported in research articles over a 30- comprehensive outcome measures needed for docu
year period. Also included in Table 2 is the number mentation of effectiveness. Often surgical interven
of subjects in each category The largest category tion was described in complex cases, such as the case
was prosthetic intervention with 21 studies (61% of reported by Johns (1985) of an individual with a
the total) followed by the surgical category with 9 gunshot wound to the left frontal lobe and the
articles (27% of the total), and the exercise catego mandible or in cases where behavioral and prosthet
ry with 2 articles (6% of the total). When interven ic intervention had already failed. Thus, the corn
tion options were compared in terms of the number plenty of the cases makes generalization to a broad
of cases or subjects reported, palatal lift interven er population difficult. Palatal lift intervention was
first reported as a response to apparent dissatisfac
tion was by far the most common with 83% of sub
tion with pharyngeal flap surgery. Hardy and his
jects (186 of 224) receiving palatal lifts. Sixteen
colleagues, who had in 1961 authored one of the first
percent of subjects received pharyngeal flap
reports of pharyngeal flap surgery, published a
surgery. However, since 1990, only 2 cases of pha
study of palatal lift intervention in 1969. As a ratio
ryngeal flap surgery were reported.
nale for the palatal lift intervention, they cited diffi
It is also important to note interventions that
culty in predicting the successful outcome with pha
were not documented in the literature. This exten
ryngeal flap surgeries. Thus, recommendations for
sive search of the published literature found no ev
the appropriateness of surgical intervention cannot
idence supporting the following techniques: push
be offered at this time given the insufficient founda
ing techniques; strengthening exercises, such as
tion of applicable research.
blowing and sucking; tasks that encourage the pa
tient to control and modify the airstream using
balls, whistles, candles, fluff; powder, paper bub Evidence for the Effectiveness
bles, straws, and so on; and inhibition techniques, of Prosthetic Intervention
such as prolonged icing, pressure to muscle inser
tion points, slow and irregular stroking and brush Because intervention studies in the area of pros
ing, and desensitization. thetic management are the most common and pro
A review of the current research suggests that vide an adequate picture of candidates and out
there is not sufficient evidence to assess the effec comes of intervention, the following sections will
tiveness of surgical management or exercise for highlight the effectiveness prosthetic intervention.
velopharyngeal impairment in dysarthria. In the
area of exercise, only two case reports have been Who Is a Good Candidate for
published. In the area of surgical intervention, evi Prosthetic Intervention?
dence is insufficient to make recommendations. Ear
ly reports draw from the field of cleft palate. In fact, Because dysarthria represents a heterogeneous
the first report of pharyngeal flap intervention in group of disorders, identifying good candidates for
neurologic populations was entitled, “Cleft palate- intervention is dependent in part upon the quality
of the description of subjects. Studies reviewed for intervention. At times, this premise was ex
here included descriptions of subject characteris pressed in procedural phrases, such as “improved
tics that ranged from comprehensive to minimal. production of plosives and fricatives with manual
The following characteristics were reported in at occlusion of the nares” (Stewart & Rieger, 1994, p.
least 50% of the studies: age, gender, medical diag 151).
nosis, time post onset, speech characteristics, treat
ment history, severity of dysarthria, physiologic da History of Previous Intervention. The history
ta, and data from the neurologic examination. of previous interventions was a common rationale
Intervention for velopharyngeal impairment was for decisions made about the chosen course of ther
studied most frequently in individual s with trau apy. For example, behavioral speech treatment had
matic brain injury (TBI), cerebrovascular accident been unsuccessful or progress had plateaued at the
(CVA), and cerebral palsy (CP). Although motor time when intervention was undertaken.
neuron disease was only reported in 5 of the 32 ar
ticles (16%), a recent study (Esposito, Mitsumoto, & Natural Course of the Disease. The course of
Shanks, 2000) reported the results of palatal lift fit the disease also was used to determine candidacy.
ting in a group of 25 speakers with amyotrophic For example, cases with the diagnosis of traumatic
lateral sclerosis. brain injury were reported where the time post on
The type of dysarthria was not specified for some set suggested that no further speech recovery was
or all of the subjects in 75% of the articles. Howev likely.
er, when the type of dysarthria was specified (as it
was in 37% articles), flaccidity was a component in Professional Judgment. Generic statements
most cases. The second most common type of about professional judgments also served as a ra
dysarthria was a mixed flaccidlspastic dysarthria. tionale for intervention. These included statements
The relatively low rate of reporting dysarthria type such as a “multidisciplinary evaluation was used to
likely reflects the historical development of the determine candidacy” (Stewart & Rieger, 1994, p.
field. The first study reporting type of dysarthria 151). The category of professional judgments also
(flaccid reported in Netsell and Daniel, 1979) oc included statements such as “other approaches
curred only after the publication of the classic such as surgery were contraindicated” (Gonzalez &
Mayo Clinic studies of differential diagnosis in Aronson, 1970, p. 92) and “interventions were
dysarthria (Darley, Aronson, & Brown, 1969a, judged to be effective for other populations particu
1969b; Darley, Aronson, & Brown, 1975). larly those with craniofacial abnormalities” (Crike
In reviewing the description of candidacy and the lair, Kastein, & Cosman, 1970, p. 182).
rationale for intervention contained in the studies,
the following general categories emerged: Patient Preferences. Statements that can be
categorized as patient preferences also emerged in
Speech Characteristics. Several speech charac discussions of candidacy (e.g., the patient was not
teristics were associated with candidacy including satisfied with the palatal lift, the palatal lift was
hypernasality, nasal emission, and severe reduc inconvenient and embarrassing in social situa
tion in intelligibility. tions, and the patient desired to permanently re
duce the impairment).
Physiologic Factors. The deficient functioning of
the velopharyngeal mechanism was identified fre How Do We Know That Treatment Works?
quently as a rationale for intervention under this One of the traditional ways of evaluating the qual
category This included characteristics such as ity of evidence that treatment works is to rate the
velopharyngeal incompetence, palatopharyngeal type of study. Studies that randomly assign sub
paralysis, inconsistent soft palatal contact with the jects into groups are generally considered the high
pharyngeal wall, and inability to achieve adequate est quality. Nonrandomized group studies or case
oral pressure. Poor respiratory support also was in subjects are generally considered to provide less
dicated as a physiologic rationale for management. powerful evidence. Given the heterogeneity of the
dysarthria population, rating of evidence by type of
Resolution of Symptoms. The notion that reso study has been called into question. (See Yorkston
lution of the velopharyngeal incompetence would et al., 2001, for a more complete discussion of the
lead to speech improvement was cited as a rationale merit of various systems for rating evidence.) In
EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 263
the current group of intervention studies focusing such as difficulty with articulation, due to in
on prosthetic management, 186 individuals with creased tonicity in laryngeallpharyngeal muscula
dysarthria were included. ture in some patients with severe spasticity. In
The psychometric adequacy of measurement was creased swallowing difficulty and hypersalivation
assessed by indicating whether information was for short periods were also reported. Finally, some
provided regarding reliability and stability of the authors reported a patient’s lack of acceptance of
measurement of the outcomes. For example, inter- the device and unrealistic expectations.
or intra-rater reliability, dispersion of judges’
scores, and comparison of measures to a gold stan What Were the Outcomes of
dard were all considered evidence of psychometric the Intervention Studies?
adequacy. Unfortunately, this type of evidence was
often lacking. Although a trend over time toward Generally, the studies of palatal lift fitting reported
more rigorous measures was noted, the majority of positive outcomes. Although criteria for success
current studies do not report evidence of psycho vary; treatment was judged successful 76% of the
metric adequacy. Overall, approximately 20% of time in a series of 25 cases reported by Bedwinek
the studies provided data about the psychometric and O’Brian (1985). Optimum results were ob
adequacy of the measures used. tained in 32 and positive outcomes in 96% of 44
Another way of rating the quality of evidence is to cases reported by LaVelle and Hardy (1979). Some
evaluate the strength of control imposed by the of the most common outcomes included improved
study; In other words, does support exist for the as articulation, improved speech intelligibility, de
sertion that the treatment of interest was responsi creased hypernasality, and more efficient use of
ble for the change in behavior/outcome measures respiratory support for speech. A more complete de
rather than some other explanation? Several studies scription of potential outcome measures can be
reported comparisons of measures of speech adequa found in the measurement of outcomes section that
cy with and without the palatal lift. This can provide follows. Palatal lift fitting was found to be success
strong evidence of internal validity (i.e., the palatal ful, but more difficult, in individuals who were
lift was responsible for the change in outcome). edentulous or had a spastic palate. The best results
Among other indicators that interventions such as were reported when the soft palate was flaccid and
palatal lifts were successful was the fact that speech when good pharyngeal wall movement was pre
performance had not improved with many years of sent. Most improvement was noted in individuals
behavioral intervention. Therefore, improvements who wore their lifts the longest.
could be attributed to palatal lift intervention. The Some of the early descriptions of palatal lift fit
trajectory of the disease also was cited as support of ting (e.g., Mazaheri & Mazaheri, 1976) posed a
the effectiveness of intervention. For some, the dis number of questions for further investigation. For
ease course was degenerative and intervention main example, what is the relationship between the
tained a given level of speech production in the face palatal stimulation offered by palatal lift fitting
of progression of the underlying impainnent. For oth and the degree of neuromuscular function and re
ers, improvement in chronic and stable conditions covery? Although many clinicians have worked
was cited as support of intervention effectiveness. with individuals who have experienced improve
ment in neuromuscular function after palatal lifts
What Risks or Complications of were fitted, studies of groups of patients fitted with
Palatal Lifts Were Identified? palatal lift prostheses did not support a strong as
sociation between palatal lift fitting and recovery of
The benefit of any intervention must be weighed velopharyngeal function (Witt et al., 1995).
against the risks or complications inherent to the Personal testimonies of speakers with dysarthria
treatment. Generally, the risks or complications of who use a palatal lift are also a source of informa
palatal lift fitting were minor. Some studies sug tion about treatment outcomes. Two of the individ
gested that tooth movement or injury to the soft tis uals with ALS who participated in the Esposito et
sue were risks, but none of the studies reported its al. study (2000) were interviewed by CBS Health-
occurrence in any subjects. The most common com watch (URL: www. cbshealthwatch.medscape, ac
plication of palatal lift fitting was intolerance in cessed 6/00). Both linked use of the lift to their con
the form of initial discomfort, inability to inhibit a tinued ability to work. One individual, a financial
gag, and prosthesis retention difficulty. Some nega planner stated, “My livelihood is based on my com
tive speech-related changes were also reported, munication skills. It is vital for me to be able to ex
264 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOG VOL.9, NO. 4
Figure 1. Diagram for clinical decision making for management of velopharyngeal impairment
in
dysarthria.
EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 265
• the velopharynx at rest and during movement • changing the level of effort (e.g., increasing
• the modified tongue-anchor test (Duffy; effort for an individual with mild velopha
1995) ryngeal weakness or decreasing effort for
• dental occlusion individuals with ataxia who exhibit a pat
• the sensitivity of the gag reflex tern of excess effort)
• swallowing ability and saliva management • monitoring excess nasal airflow and reso
• signs of a submucous cleft (Kruminer & nance features
Lee, 1996; Wolfaardt et al., 1993). • increasing the precision of speech by exag
gerating articulatory movements (“clear
speech”)
Instrumental Examination of the
Velopharyngeal Mechanism Decisions about how to treat patients with
velopharyngeal impairment of moderate severity
Instrumental examination of the velopharyngeal can be difficult. For example, expert opinion differs
mechanism is necessary to directly observe and somewhat regarding the timing of palatal lift in
measure velopharyngeal activity (Duffy, 1995; Till, tervention hi moderately severe cases. Some argue
Jafari, & Law-Till, 1994; Wolfaardt et al., 1993). that velopharyngeal management should be car
Instrumentation may include videoflouroscopy, ried out prior to phonation, articulation, andlor
nasoendoscopy, aerodynamic (pressure-flow) as prosody exercises for speakers who are recovering
sessments, and acoustic assessment. This instru function. Others would suggest that velopharyn
mentation allows for the evaluation of geal management should occur only after the
speaker can phonate voluntarily. The clinician
• intraoral air pressure and nasal airflow needs to consider several factors, including the rel
during production of pressure consonants ative severity of involvement in other functional
• palatal movement components, to determine whether treatment of
• lateral pharyngeal wall movement the velopharynx would enhance function in other
• sphincteric activity during speech areas (e.g., tax respiration less), and whether
• nasal airflow and intraoral air pressure velopharyngeal function would benefit from treat
• the timing of velopharygeal movements ing other components first or from modifying the
patient’s speaking rate or effort (Netsell & Rosen
Behavioral Intervention bek, 1985).
The assessment of velopharyngeal function leads to
one of two conclusions (see Figure 1): adequate Techniques Focusing on Speech Production
velopharyngeal function or velopharyngeal impair
A variety of behavioral interventions have been
ment. If velopharyngeal function is judged to be ad
recommended for individuals with dysarthria. Be
equate, those individuals with progressive disor
cause velopharyngeal impairment may be mild and
ders are followed and reassessed. If velopharygneal
part of a pattern of impairment crossing multiple
impairment is identified, then decisions are made
speech subsystems, this type of intervention is con
about the appropriateness of behavioral interven
tions. Generally, those individuals who are appro sidered the most common treatment of velopharyn
priate for behavioral intervention are those who geal impairment in dysarthria. It should be noted
can compensate (or will be able to compensate if re that most behavioral interventions for velopharyn
covery continues) for the velopharyneal impair geal impairment suggested here arise from expert
ment (Netsell & Rosenbek, 1985). The question of opinion rather than from research findings. It
whether or not speakers are able to compensate for should also be noted that there is little guidance
velopharyngeal impairment can be addressed by from the evidence or expert opinion about how long
evaluating stimulability (the ability to improve these interventions should be applied before either
performance under certain conditions). The follow an effect can be expected or the intervention aban
ing techniques can be used to assess stimulability: doned. These techniques will be reviewed in more
detail in subsequent modules of the Practice Guide
• changing speaking rate (e.g., slowing the lines for Dysarthria. Generally, the behavioral
speaking rate) techniques include the following:
EVIDENCE-BASED PRACTICE GUIDELINES FOR DYSARTHRIA 267
Modifying the Pattern of Speaking. Examples no evidence exists that increasing soft palate
of such modifications include producing speech strength improves speech performance; and (c)
with increased effort (Liss, Kuehn, & Hinkle, 1994) most of the methods do not provide the patient
or a slower rate (Yorkston & Beukelman, 1981; with information on the timing of articulatory ges
Yorkston, Beukelman, Strand, & Bell, 1999). tures during speech (Murdoch et al., 1997). Evi
Speakers can also be trained to produce clear dence and expert opinion suggest that the following
speech by mimicking the overarticulated speech of techniques for improving velopharyngeal function
a trained talker. Overarticulated speech can be are not effective (Brookshire, 1992; Duffy, 1995;
elicited by prompting with comments like, “open Dworkin & Johns, 1980; Hageman, 1997; Johns,
your mouth more,” “speak more clearly,” “overartic 1985; Murdoch et al., 1997; Netsell & Rosenbek,
ulate,” and “talk slowly” (Picheny, Durlach, & Brai 1985; Yorkston et al., 1999):
da, 1985).
• Pushing techniques (particularly for pa
Resistance Treatment During Speech. Con tients with spastic dysarthria)
tinuous positive airway pressure (CPAP) is an • Strengthening exercises, such as blowing
emerging intervention technique reported to be an and sucking
effective means of exercising the soft palate during • Tasks that encourage the patient to control
speech in two individuals with traumatic brain in and modify the airstream using balls, whis
jury The technique provides a resistance against tles, candles, fluff; powder; paper; bubbles,
which the muscles of velopharyngeal closure must straws, etc.
work (Kuehn, 1997; Kuehn & Wachtel, 1994). A • Inhibition techniques, such as prolonged
theoretical rationale for strength training is avail icing, pressure to muscle insertion points,
able (Liss, Kuehn, & Hinkle, 1994). slow and irregular stroking and brushing,
and desensitization.
Feedback. The use of biofeedback techniques for
therapy has been suggested for velopharyngeal im Prosthetic Intervention
pairment in dysarthria. Some speakers may bene
fit from feedback from a mirror, nasal flow trans Candidacy for Palatal Lift Fitting
ducer, or nasoendoscope during efforts to decrease
nasal air flow and hypernasality (Rosenbek & La If assessment reveals that velopharyrigeal impair
Pointe, 1985). The following are some of the instru ment is present and the speaker is not able to com
mental feedback techniques discussed in a chapter pensate for that impairment, a palatal lift prosthe
by Murdoch, Thompson, and Theodoros (1997) on sis may be considered for selected cases, especially
spastic dysarthria: those with a flaccid soft palate. A palatal lift is a
rigid acrylic appliance fabricated by a prosthodon
• flexible endoscope (provides visual feed tist. It consists of a retentive portion that covers the
back of the movements of the lateral pha hard palate and fastens to the maxillary teeth by
ryngeal wall) means of wires and a lift portion that extends along
• fiberoptic nasopharyngoscopes (obtains the oral surface of the soft palate. Issues regarding
close observations of VP sphincter during candidacy for palatal lift fitting have been de
connected speech) scribed extensively (Bedwinek & O’Brian, 1985;
• Exeter Bio-Feedback Nasal Anemometer Duffy 1995; Esposito et al., 2000; Murdoch et aL,
(EBNA; Bioinstrumentation LTD Exeter) 1997; Netsell, 1998; Yorkston et aL, 1999). Because
timing of intervention is different for individuals
Techniques Focusing on with progressive as opposed to stable-recovering
Nonspeech Movements dysarthrias, candidacy in each population will be
discussed separately.
Therapy techniques appear in the literature that
are based primarily on nonspeech movements of Progressive Dysartbria. Table 3 ifiustrates char
the velopharyngeal mechanism. These have gener acteristics of better versus poorer candidates for
ally not been endorsed by experts for several rea palatal lift fitting in progressive dysarthria. Better
sons: (a) speech and nonspeech velopharyngeal clo candidates are those with a slow rate of disease
sures involve different underlying mechanisms; (b) progression and intact cognition, memory, judg
268 JOURNAL OF MEDICAL SPEECH-LANGUA
GE PATHOLOGY, VOL.9, NO. 4
TABLE 3. Characteristics of better and poorer cand
idates for palatal lift fitting in progressive dysarthria.
TABLE 4. Characteristics of better and poorer candidates for palatal lift fitting in stable or recovering dysarthria.
thologist to adjust the length and torque of dysarthria. The speaker points to the first
the lift to maximize fitting. letter of each word as that word is spoken.
Follow-up visits are planned to monitor the • Partner techniques are strategies initiated
adequacy of the fitting. According to Espos by the communication partner including
ito and colleagues (2000), prosthetic treat maintaining the topic identity, paying undi
ment for progressive disorders must be vided attention, and piecing together cues
ongoing. Modifications to the prosthesis are from the speaker with dysarthria.
made on a regular basis to accommodate for • Speaker strategies are used to heighten the
the progression of the disease. It is common intelligibility of severely dysarthric speech,
to make changes to the lift and the augmen including the use of gestures, selecting a
tation of the hard palate portion for speak conducive communication environment,
ers with increasingly severe dysarthria. and using turn maintenance signals.
• Augmentative and alternative communica
Behavioral Intervention for Poor tion techniques include use of devices to
Candidates for Palatal Lifts replace or supplement highly distorted speech
(Beukelman, Yorkston, & Reichle, 2000).
If the speaker is judged to be a poor candidate for
palatal lift fitting, several behavioral strategies are Surgical Intervention
available to establish or maintain communicative
function (Hustad & Beukelman, 2000; Yorkston et Surgical management for velopharyngeal impair
al., 1999). Behavioral intervention may be em ment in dysarthric speakers also has been report
ployed so that speakers can improve the effective ed. Generally, it is considered less beneficial than
ness of their communication. The following specific prosthetic management and is contraindicated in
techniques will be reviewed in subsequent modules children with cerebral palsy (Hardy et al, 1961;
of the Practice Guidelines for Dysarthria: Lotz & Netsell, 1989). Johns (1985), however, sum
marized his positive experiences with a substantial
Alphabet supplementation is a technique number of dysarthric speakers with velopharyn
to improve intelligibility in severe geal impairment who had superiorly based pha
HOLOG VOL.9, NO. 4
270 JOURNAL OF MEDICAL SPEECH-LANGUAGE PAT
Address correspondence to Kathryn M. Yorkston, *Esposito, S. J., Mitsumoto, H., & Shanks, M. (2000).
Ph.D., Rehabilitation Medicine, Box 356490, University Use of palatal lift and palatal augmentation prosthe
of Washington, Seattle, WA 98195-6490 USA. ses to improve dysarthria in patients with amy
e-mail: yorkston@u.washington.edu otrophic lateral sclerosis: A case series. Journal of
Prosthetic Dentistry, 83, 90—98.
Frattali, C. (1998). Outcomes measurement: Definitions,
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